The role of lung microbiome in the occurrence, diagnosis and immunotherapy of lung cancer_West China Medical Journal

Authors：

TIAN Xia ,  TIAN Panwen , LI Weimin

Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

TIAN Panwen, Email: mrascend@163.com

Keywords：

Lung microbiome; Lung cancer; Immunotherapy

DOI：

10.7507/1002-0179.202012089

Video：

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Abstract Full text Figures/Tables Video References Cited by

Lung microbiome is defined as the specific microbiota of lung. Lung microbiome can make the lung in a state of chronic inflammation through direct destruction, activation of inflammatory cells and release of inflammatory factors, and then progress to lung cancer. There are significant differences in lung microbiome between lung cancer patients and healthy people. Some specific microbial flora can be used as a diagnostic marker of lung cancer. Specific microbial communities are related to the efficacy of immunotherapy, and microbial composition may be used as a marker of immune-related adverse events. There are both challenges and opportunities for research on the relationship between lung microbiome and lung cancer. This review will focus on the significance and value of lung microbiome in the occurrence, diagnosis and immunotherapy of lung cancer, in order to provide a reference for basic and clinical researchers in related fields.

Citation： TIAN Xia, TIAN Panwen, LI Weimin. The role of lung microbiome in the occurrence, diagnosis and immunotherapy of lung cancer. West China Medical Journal, 2021, 36(1): 14-18. doi: 10.7507/1002-0179.202012089 Copy

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2.	Thorpe JE, Baughman RP, Frame PT, et al. Bronchoalveolar lavage for diagnosing acute bacterial pneumonia. J Infect Dis, 1987, 155(5): 855-861.
3.	Gensollen T, Iyer SS, Kasper DL, et al. How colonization by microbiota in early life shapes the immune system. Science, 2016, 352(6285): 539-544.
4.	Durack J, Lynch SV, Nariya S, et al. Features of the bronchial bacterial microbiome associated with atopy, asthma, and responsiveness to inhaled corticosteroid treatment. J Allergy Clin Immunol, 2017, 140(1): 63-75.
5.	Dickson RP, Huffnagle GB. The lung microbiome: new principles for respiratory bacteriology in health and disease. PLoS Pathog, 2015, 11(7): e1004923.
6.	Kovaleva OV, Romashin D, Zborovskaya IB, et al. Human lung microbiome on the way to cancer. J Immunol Res, 2019, 2019: 1394191.
7.	García-Castillo V, Sanhueza E, McNerney E, et al. Microbiota dysbiosis: a new piece in the understanding of the carcinogenesis puzzle. J Med Microbiol, 2016, 65(12): 1347-1362.
8.	Abenavoli L, Scarpellini E, Colica C, et al. Gut microbiota and obesity: a role for probiotics. Nutrients, 2019, 11(11): 2690.
9.	Hills RD Jr, Pontefract BA, Mishcon HR, et al. Gut microbiome: profound implications for diet and disease. Nutrients, 2019, 11(7): 1613.
10.	Dickson RP, Erb-Downward JR, Martinez FJ, et al. The microbiome and the respiratory tract. Annu Rev Physiol, 2016, 78: 481-504.
11.	Mathieu E, Escribano-Vazquez U, Descamps D, et al. Paradigms of lung microbiota functions in health and disease, particularly, in asthma. Front Physiol, 2018, 9: 1168.
12.	Gollwitzer ES, Saglani S, Trompette A, et al. Lung microbiota promotes tolerance to allergens in neonates via PD-L1. Nat Med, 2014, 20(6): 642-647.
13.	Rubtsov YP, Rasmussen JP, Chi EY, et al. Regulatory T cell-derived interleukin-10 limits inflammation at environmental interfaces. Immunity, 2008, 28(4): 546-558.
14.	Hussell T, Bell TJ. Alveolar macrophages: plasticity in a tissue-specific context. Nat Rev Immunol, 2014, 14(2): 81-93.
15.	Soroosh P, Doherty TA, Duan W, et al. Lung-resident tissue macrophages generate Foxp3+ regulatory T cells and promote airway tolerance. J Exp Med, 2013, 210(4): 775-788.
16.	Tanaka A, Sakaguchi S. Regulatory T cells in cancer immunotherapy. Cell Res, 2017, 27(1): 109-118.
17.	Segal LN, Clemente JC, Tsay JC, et al. Enrichment of the lung microbiome with oral taxa is associated with lung inflammation of a Th17 phenotype. Nat Microbiol, 2016, 1: 16031.
18.	Theodoratou E, Timofeeva M, Li X, et al. Nature, nurture, and cancer risks: genetic and nutritional contributions to cancer. Annu Rev Nutr, 2017, 37: 293-320.
19.	Bose S, Allen AE, Locasale JW. The molecular link from diet to cancer cell metabolism. Mol Cell, 2020, 80(3): 554.
20.	Zhu J, Thompson CB. Metabolic regulation of cell growth and proliferation. Nat Rev Mol Cell Biol, 2019, 20(7): 436-450.
21.	Petrelli F, Ghidini M, Ghidini A, et al. Use of antibiotics and risk of cancer: a systematic review and meta-analysis of observational studies. Cancers (Basel), 2019, 11(8): 1174.
22.	Kearney SC, Dziekiewicz M, Feleszko W. Immunoregulatory and immunostimulatory responses of bacterial lysates in respiratory infections and asthma. Ann Allergy Asthma Immunol, 2015, 114(5): 364-369.
23.	Chuquimia OD, Petursdottir DH, Periolo N, et al. Alveolar epithelial cells are critical in protection of the respiratory tract by secretion of factors able to modulate the activity of pulmonary macrophages and directly control bacterial growth. Infect Immun, 2013, 81(1): 381-389.
24.	Takeuchi O, Akira S. Pattern recognition receptors and inflammation. Cell, 2010, 140(6): 805-820.
25.	Apopa PL, Alley L, Penney RB, et al. PARP1 is up-regulated in non-small cell lung cancer tissues in the presence of the cyanobacterial toxin microcystin. Front Microbiol, 2018, 9: 1757.
26.	Jungnickel C, Schmidt LH, Bittigkoffer L, et al. IL-17C mediates the recruitment of tumor-associated neutrophils and lung tumor growth. Oncogene, 2017, 36(29): 4182-4190.
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28.	Jin C, Lagoudas GK, Zhao C, et al. Commensal microbiota promote lung cancer development via γδ T cells. Cell, 2019, 176(5): 998-1013. e16.
29.	Tsay JJ, Wu BG, Badri MH, et al. Airway microbiota is associated with upregulation of the PI3K pathway in lung cancer. Am J Respir Crit Care Med, 2018, 198(9): 1188-1198.
30.	Sears CL, Geis AL, Housseau F. Bacteroides fragilis subverts mucosal biology: from symbiont to colon carcinogenesis. J Clin Invest, 2014, 124(10): 4166-4172.
31.	Yu G, Gail MH, Consonni D, et al. Characterizing human lung tissue microbiota and its relationship to epidemiological and clinical features. Genome Biol, 2016, 17(1): 163.
32.	Hosgood HD 3rd, Sapkota AR, Rothman N, et al. The potential role of lung microbiota in lung cancer attributed to household coal burning exposures. Environ Mol Mutagen, 2014, 55(8): 643-651.
33.	Lee SH, Sung JY, Yong D, et al. Characterization of microbiome in bronchoalveolar lavage fluid of patients with lung cancer comparing with benign mass like lesions. Lung Cancer, 2016, 102: 89-95.
34.	Laroumagne S, Lepage B, Hermant C, et al. Bronchial colonisation in patients with lung cancer: a prospective study. Eur Respir J, 2013, 42(1): 220-229.
35.	Yan X, Yang M, Liu J, et al. Discovery and validation of potential bacterial biomarkers for lung cancer. Am J Cancer Res, 2015, 5(10): 3111-3122.
36.	Greathouse KL, White JR, Vargas AJ, et al. Interaction between the microbiome and TP53 in human lung cancer. Genome Biol, 2018, 19(1): 123.
37.	Cheng C, Wang Z, Wang J, et al. Characterization of the lung microbiome and exploration of potential bacterial biomarkers for lung cancer. Transl Lung Cancer Res, 2020, 9(3): 693-704.
38.	Chen DS, Mellman I. Oncology meets immunology: the cancer-immunity cycle. Immunity, 2013, 39(1): 1-10.
39.	Ott PA, Hodi FS, Robert C. CTLA-4 and PD-1/PD-L1 blockade: new immunotherapeutic modalities with durable clinical benefit in melanoma patients. Clin Cancer Res, 2013, 19(19): 5300-5309.
40.	Dong Y, Sun Q, Zhang X. PD-1 and its ligands are important immune checkpoints in cancer. Oncotarget, 2017, 8(2): 2171-2186.
41.	Alsaab HO, Sau S, Alzhrani R, et al. PD-1 and PD-L1 checkpoint signaling inhibition for cancer immunotherapy: mechanism, combinations, and clinical outcome. Front Pharmacol, 2017, 8: 561.
42.	Bristol-Myers Squibb. Opdivo (Nivolumab) package insert. (2018-04-16)[2021-01-13]. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125554s058lbl.pdf.
43.	Bristol-Myers Squibb Pharma EEIG. Summary of product characteristics. (2017-03-30)[2021-01-13]. https://www.ema.europa.eu/en/documents/product-information/opdivo-epar-product-information_en.pdf.
44.	Yang X, Yin R, Xu L. Neoadjuvant PD-1 blockade in resectable lung cancer. N Engl J Med, 2018, 379(9): e14.
45.	Aguilar EJ, Ricciuti B, Gainor JF, et al. Outcomes to first-line pembrolizumab in patients with non-small-cell lung cancer and very high PD-L1 expression. Ann Oncol, 2019, 30(10): 1653-1659.
46.	Herbst RS, Baas P, Kim DW, et al. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial. Lancet, 2016, 387(10027): 1540-1550.
47.	Horn L, Spigel DR, Vokes EE, et al. Nivolumab versus docetaxel in previously treated patients with advanced non-small-cell lung cancer: two-year outcomes from two randomized, open-label, phase Ⅲ trials (CheckMate 017 and CheckMate 057). J Clin Oncol, 2017, 35(35): 3924-3933.
48.	Rittmeyer A, Barlesi F, Waterkamp D, et al. Atezolizumab versus docetaxel in patients with previously treated non-small-cell lung cancer (OAK): a phase 3, open-label, multicentre randomised controlled trial. Lancet, 2017, 389(10066): 255-265.
49.	Rizvi NA, Hellmann MD, Snyder A, et al. Cancer immunology. Mutational landscape determines sensitivity to PD-1 blockade in non-small cell lung cancer. Science, 2015, 348(6230): 124-128.
50.	Baretti M, Le DT. DNA mismatch repair in cancer. Pharmacol Ther, 2018, 189: 45-62.
51.	Belkaid Y, Hand TW. Role of the microbiota in immunity and inflammation. Cell, 2014, 157(1): 121-141.
52.	Matson V, Fessler J, Bao R, et al. The commensal microbiome is associated with anti-PD-1 efficacy in metastatic melanoma patients. Science, 2018, 359(6371): 104-108.
53.	Routy B, Le Chatelier E, Derosa L, et al. Gut microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors. Science, 2018, 359(6371): 91-97.
54.	Sivan A, Corrales L, Hubert N, et al. Commensal Bifidobacterium promotes antitumor immunity and facilitates anti-PD-L1 efficacy. Science, 2015, 350(6264): 1084-1089.
55.	Derosa L, Hellmann MD, Spaziano M, et al. Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer. Ann Oncol, 2018, 29(6): 1437-1444.
56.	Pinato DJ, Howlett S, Ottaviani D, et al. Association of prior antibiotic treatment with survival and response to immune checkpoint inhibitor therapy in patients with cancer. JAMA Oncol, 2019, 5(12): 1774-1778.
57.	Wilson BE, Routy B, Nagrial A, et al. The effect of antibiotics on clinical outcomes in immune-checkpoint blockade: a systematic review and meta-analysis of observational studies. Cancer Immunol Immunother, 2020, 69(3): 343-354.
58.	Pinato DJ, Gramenitskaya D, Altmann DM, et al. Antibiotic therapy and outcome from immune-checkpoint inhibitors. J Immunother Cancer, 2019, 7(1): 287.
59.	Lurienne L, Cervesi J, Duhalde L, et al. NSCLC immunotherapy efficacy and antibiotic use: a systematic review and meta-analysis. J Thorac Oncol, 2020, 15(7): 1147-1159.
60.	Tinsley N, Zhou C, Tan G, et al. Cumulative antibiotic use significantly decreases efficacy of checkpoint inhibitors in patients with advanced cancer. Oncologist, 2020, 25(1): 55-63.
61.	Wang F, Yin Q, Chen L, et al. Bifidobacterium can mitigate intestinal immunopathology in the context of CTLA-4 blockade. Proc Natl Acad Sci U S A, 2018, 115(1): 157-161.

1. Hirsch FR, Scagliotti GV, Mulshine JL, et al. Lung cancer: current therapies and new targeted treatments. Lancet, 2017, 389(10066): 299-311.
2. Thorpe JE, Baughman RP, Frame PT, et al. Bronchoalveolar lavage for diagnosing acute bacterial pneumonia. J Infect Dis, 1987, 155(5): 855-861.
3. Gensollen T, Iyer SS, Kasper DL, et al. How colonization by microbiota in early life shapes the immune system. Science, 2016, 352(6285): 539-544.
4. Durack J, Lynch SV, Nariya S, et al. Features of the bronchial bacterial microbiome associated with atopy, asthma, and responsiveness to inhaled corticosteroid treatment. J Allergy Clin Immunol, 2017, 140(1): 63-75.
5. Dickson RP, Huffnagle GB. The lung microbiome: new principles for respiratory bacteriology in health and disease. PLoS Pathog, 2015, 11(7): e1004923.
6. Kovaleva OV, Romashin D, Zborovskaya IB, et al. Human lung microbiome on the way to cancer. J Immunol Res, 2019, 2019: 1394191.
7. García-Castillo V, Sanhueza E, McNerney E, et al. Microbiota dysbiosis: a new piece in the understanding of the carcinogenesis puzzle. J Med Microbiol, 2016, 65(12): 1347-1362.
8. Abenavoli L, Scarpellini E, Colica C, et al. Gut microbiota and obesity: a role for probiotics. Nutrients, 2019, 11(11): 2690.
9. Hills RD Jr, Pontefract BA, Mishcon HR, et al. Gut microbiome: profound implications for diet and disease. Nutrients, 2019, 11(7): 1613.
10. Dickson RP, Erb-Downward JR, Martinez FJ, et al. The microbiome and the respiratory tract. Annu Rev Physiol, 2016, 78: 481-504.
11. Mathieu E, Escribano-Vazquez U, Descamps D, et al. Paradigms of lung microbiota functions in health and disease, particularly, in asthma. Front Physiol, 2018, 9: 1168.
12. Gollwitzer ES, Saglani S, Trompette A, et al. Lung microbiota promotes tolerance to allergens in neonates via PD-L1. Nat Med, 2014, 20(6): 642-647.
13. Rubtsov YP, Rasmussen JP, Chi EY, et al. Regulatory T cell-derived interleukin-10 limits inflammation at environmental interfaces. Immunity, 2008, 28(4): 546-558.
14. Hussell T, Bell TJ. Alveolar macrophages: plasticity in a tissue-specific context. Nat Rev Immunol, 2014, 14(2): 81-93.
15. Soroosh P, Doherty TA, Duan W, et al. Lung-resident tissue macrophages generate Foxp3+ regulatory T cells and promote airway tolerance. J Exp Med, 2013, 210(4): 775-788.
16. Tanaka A, Sakaguchi S. Regulatory T cells in cancer immunotherapy. Cell Res, 2017, 27(1): 109-118.
17. Segal LN, Clemente JC, Tsay JC, et al. Enrichment of the lung microbiome with oral taxa is associated with lung inflammation of a Th17 phenotype. Nat Microbiol, 2016, 1: 16031.
18. Theodoratou E, Timofeeva M, Li X, et al. Nature, nurture, and cancer risks: genetic and nutritional contributions to cancer. Annu Rev Nutr, 2017, 37: 293-320.
19. Bose S, Allen AE, Locasale JW. The molecular link from diet to cancer cell metabolism. Mol Cell, 2020, 80(3): 554.
20. Zhu J, Thompson CB. Metabolic regulation of cell growth and proliferation. Nat Rev Mol Cell Biol, 2019, 20(7): 436-450.
21. Petrelli F, Ghidini M, Ghidini A, et al. Use of antibiotics and risk of cancer: a systematic review and meta-analysis of observational studies. Cancers (Basel), 2019, 11(8): 1174.
22. Kearney SC, Dziekiewicz M, Feleszko W. Immunoregulatory and immunostimulatory responses of bacterial lysates in respiratory infections and asthma. Ann Allergy Asthma Immunol, 2015, 114(5): 364-369.
23. Chuquimia OD, Petursdottir DH, Periolo N, et al. Alveolar epithelial cells are critical in protection of the respiratory tract by secretion of factors able to modulate the activity of pulmonary macrophages and directly control bacterial growth. Infect Immun, 2013, 81(1): 381-389.
24. Takeuchi O, Akira S. Pattern recognition receptors and inflammation. Cell, 2010, 140(6): 805-820.
25. Apopa PL, Alley L, Penney RB, et al. PARP1 is up-regulated in non-small cell lung cancer tissues in the presence of the cyanobacterial toxin microcystin. Front Microbiol, 2018, 9: 1757.
26. Jungnickel C, Schmidt LH, Bittigkoffer L, et al. IL-17C mediates the recruitment of tumor-associated neutrophils and lung tumor growth. Oncogene, 2017, 36(29): 4182-4190.
27. Chang SH, Mirabolfathinejad SG, Katta H, et al. T helper 17 cells play a critical pathogenic role in lung cancer. Proc Natl Acad SciU S A, 2014, 111(15): 5664-5669.
28. Jin C, Lagoudas GK, Zhao C, et al. Commensal microbiota promote lung cancer development via γδ T cells. Cell, 2019, 176(5): 998-1013. e16.
29. Tsay JJ, Wu BG, Badri MH, et al. Airway microbiota is associated with upregulation of the PI3K pathway in lung cancer. Am J Respir Crit Care Med, 2018, 198(9): 1188-1198.
30. Sears CL, Geis AL, Housseau F. Bacteroides fragilis subverts mucosal biology: from symbiont to colon carcinogenesis. J Clin Invest, 2014, 124(10): 4166-4172.
31. Yu G, Gail MH, Consonni D, et al. Characterizing human lung tissue microbiota and its relationship to epidemiological and clinical features. Genome Biol, 2016, 17(1): 163.
32. Hosgood HD 3rd, Sapkota AR, Rothman N, et al. The potential role of lung microbiota in lung cancer attributed to household coal burning exposures. Environ Mol Mutagen, 2014, 55(8): 643-651.
33. Lee SH, Sung JY, Yong D, et al. Characterization of microbiome in bronchoalveolar lavage fluid of patients with lung cancer comparing with benign mass like lesions. Lung Cancer, 2016, 102: 89-95.
34. Laroumagne S, Lepage B, Hermant C, et al. Bronchial colonisation in patients with lung cancer: a prospective study. Eur Respir J, 2013, 42(1): 220-229.
35. Yan X, Yang M, Liu J, et al. Discovery and validation of potential bacterial biomarkers for lung cancer. Am J Cancer Res, 2015, 5(10): 3111-3122.
36. Greathouse KL, White JR, Vargas AJ, et al. Interaction between the microbiome and TP53 in human lung cancer. Genome Biol, 2018, 19(1): 123.
37. Cheng C, Wang Z, Wang J, et al. Characterization of the lung microbiome and exploration of potential bacterial biomarkers for lung cancer. Transl Lung Cancer Res, 2020, 9(3): 693-704.
38. Chen DS, Mellman I. Oncology meets immunology: the cancer-immunity cycle. Immunity, 2013, 39(1): 1-10.
39. Ott PA, Hodi FS, Robert C. CTLA-4 and PD-1/PD-L1 blockade: new immunotherapeutic modalities with durable clinical benefit in melanoma patients. Clin Cancer Res, 2013, 19(19): 5300-5309.
40. Dong Y, Sun Q, Zhang X. PD-1 and its ligands are important immune checkpoints in cancer. Oncotarget, 2017, 8(2): 2171-2186.
41. Alsaab HO, Sau S, Alzhrani R, et al. PD-1 and PD-L1 checkpoint signaling inhibition for cancer immunotherapy: mechanism, combinations, and clinical outcome. Front Pharmacol, 2017, 8: 561.
42. Bristol-Myers Squibb. Opdivo (Nivolumab) package insert. (2018-04-16)[2021-01-13]. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125554s058lbl.pdf.
43. Bristol-Myers Squibb Pharma EEIG. Summary of product characteristics. (2017-03-30)[2021-01-13]. https://www.ema.europa.eu/en/documents/product-information/opdivo-epar-product-information_en.pdf.
44. Yang X, Yin R, Xu L. Neoadjuvant PD-1 blockade in resectable lung cancer. N Engl J Med, 2018, 379(9): e14.
45. Aguilar EJ, Ricciuti B, Gainor JF, et al. Outcomes to first-line pembrolizumab in patients with non-small-cell lung cancer and very high PD-L1 expression. Ann Oncol, 2019, 30(10): 1653-1659.
46. Herbst RS, Baas P, Kim DW, et al. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial. Lancet, 2016, 387(10027): 1540-1550.
47. Horn L, Spigel DR, Vokes EE, et al. Nivolumab versus docetaxel in previously treated patients with advanced non-small-cell lung cancer: two-year outcomes from two randomized, open-label, phase Ⅲ trials (CheckMate 017 and CheckMate 057). J Clin Oncol, 2017, 35(35): 3924-3933.
48. Rittmeyer A, Barlesi F, Waterkamp D, et al. Atezolizumab versus docetaxel in patients with previously treated non-small-cell lung cancer (OAK): a phase 3, open-label, multicentre randomised controlled trial. Lancet, 2017, 389(10066): 255-265.
49. Rizvi NA, Hellmann MD, Snyder A, et al. Cancer immunology. Mutational landscape determines sensitivity to PD-1 blockade in non-small cell lung cancer. Science, 2015, 348(6230): 124-128.
50. Baretti M, Le DT. DNA mismatch repair in cancer. Pharmacol Ther, 2018, 189: 45-62.
51. Belkaid Y, Hand TW. Role of the microbiota in immunity and inflammation. Cell, 2014, 157(1): 121-141.
52. Matson V, Fessler J, Bao R, et al. The commensal microbiome is associated with anti-PD-1 efficacy in metastatic melanoma patients. Science, 2018, 359(6371): 104-108.
53. Routy B, Le Chatelier E, Derosa L, et al. Gut microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors. Science, 2018, 359(6371): 91-97.
54. Sivan A, Corrales L, Hubert N, et al. Commensal Bifidobacterium promotes antitumor immunity and facilitates anti-PD-L1 efficacy. Science, 2015, 350(6264): 1084-1089.
55. Derosa L, Hellmann MD, Spaziano M, et al. Negative association of antibiotics on clinical activity of immune checkpoint inhibitors in patients with advanced renal cell and non-small-cell lung cancer. Ann Oncol, 2018, 29(6): 1437-1444.
56. Pinato DJ, Howlett S, Ottaviani D, et al. Association of prior antibiotic treatment with survival and response to immune checkpoint inhibitor therapy in patients with cancer. JAMA Oncol, 2019, 5(12): 1774-1778.
57. Wilson BE, Routy B, Nagrial A, et al. The effect of antibiotics on clinical outcomes in immune-checkpoint blockade: a systematic review and meta-analysis of observational studies. Cancer Immunol Immunother, 2020, 69(3): 343-354.
58. Pinato DJ, Gramenitskaya D, Altmann DM, et al. Antibiotic therapy and outcome from immune-checkpoint inhibitors. J Immunother Cancer, 2019, 7(1): 287.
59. Lurienne L, Cervesi J, Duhalde L, et al. NSCLC immunotherapy efficacy and antibiotic use: a systematic review and meta-analysis. J Thorac Oncol, 2020, 15(7): 1147-1159.
60. Tinsley N, Zhou C, Tan G, et al. Cumulative antibiotic use significantly decreases efficacy of checkpoint inhibitors in patients with advanced cancer. Oncologist, 2020, 25(1): 55-63.
61. Wang F, Yin Q, Chen L, et al. Bifidobacterium can mitigate intestinal immunopathology in the context of CTLA-4 blockade. Proc Natl Acad Sci U S A, 2018, 115(1): 157-161.

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